What supplement regimen is recommended for adults aged ≥65 years (especially ≥80 years) to correct common deficiencies and avoid excesses?

Supplement Recommendations for Elderly and Geriatric Populations

Core Recommendation

Elderly adults aged ≥65 years should receive vitamin D 800 IU daily, calcium supplementation to reach 1,200 mg total daily intake (prioritizing dietary sources first), and vitamin B12 supplementation at 4-6 μg/day, while a daily multivitamin containing complete micronutrients (both vitamins and trace elements) is appropriate for those with reduced dietary intake (<1,500 kcal/day), malnutrition risk, or institutionalization. 1, 2, 3

---

Universal Supplements for All Elderly ≥65 Years

Vitamin D

• All adults ≥65 years should take 800 IU vitamin D3 daily, year-round, regardless of dietary intake or sun exposure. 2
• This dosing reduces hip fractures by 30% and non-vertebral fractures by 14% in this age group. 2
• Target serum 25(OH)D level: 20-30 ng/mL for optimal bone health. 2
• Dietary sources and sunlight are insufficient in elderly populations, particularly those homebound or institutionalized. 2

Calcium

• Target 1,200 mg total daily calcium for women >50 and men >70 years. 1, 2
• Prioritize dietary sources first: Each dairy serving provides ~300 mg; non-dairy sources contribute ~300 mg daily. 2
• Supplement only the gap: If dietary intake falls short, add 500-900 mg supplementation. 2
• Use calcium citrate preferentially because it doesn't require gastric acid for absorption, can be taken with or without food, and has fewer gastrointestinal side effects—critical for elderly with hypochlorhydria or antacid use. 2

Vitamin B12

• All elderly should receive 4-6 μg/day of vitamin B12. 1, 3
• The UK RNI of 1.5 μg/day is inadequate; European recommendations of 4-6 μg/day better normalize functional markers. 3
• Rationale: 12-20% of elderly have vitamin B12 deficiency despite adequate intake due to atrophic gastritis and widespread antacid/PPI use impairing absorption. 4, 3
• Fortified breakfast cereals provide practical B12 delivery. 2, 3

---

Conditional Multivitamin Supplementation

When to Prescribe Complete Multivitamin/Multi-Trace Element Supplements

Prescribe complete micronutrient supplementation (both multivitamins AND multi-trace elements, not vitamins alone) for: 4, 1

• Reduced energy intake (<1,500 kcal/day) 1
• Documented malnutrition or at nutritional risk (involuntary weight loss >10 pounds or >10% body weight in <6 months) 1
• Institutionalized elderly or long-term care residents 4
• Frail elderly with multiple comorbidities 4
• Lower socioeconomic status or limited dietary variety 2

Critical Caveat on Supplement Composition

• General micronutrient supplementation must include BOTH multivitamins AND multi-trace elements, not multivitamins alone. 4
• Provision of multivitamins without trace elements is common due to cost but inadequate for those with general micronutrient depletion. 4

When NOT to Prescribe Multivitamins

• Healthy, well-nourished community-dwelling elderly with adequate dietary intake do not benefit from routine multivitamin supplementation. 1
• The USPSTF finds insufficient evidence for multivitamins preventing cardiovascular disease or cancer in healthy adults. 1

---

Specific High-Risk Deficiencies in Elderly

B Vitamins Beyond B12

• 16-19% of elderly have intakes below recommended levels for B vitamins. 4, 5
• Folate deficiency: 2-15% of elderly 2
• Riboflavin deficiency: >50% of elderly 2
• Vitamin B6 deficiency: 12% of elderly 2
• Thiamin deficiency is common and mimics sarcopenia features (reduced appetite, weight loss, neuromuscular compromise). 4
• Fortified breakfast cereals effectively improve B vitamin status. 2

Other Common Deficiencies

• Vitamin C, zinc, and magnesium deficiencies are prevalent in elderly. 1
• Selenium, thiamin, and riboflavin are possible public health concerns based on dietary intake analysis. 5

---

Supplements to AVOID in Elderly

Explicitly Contraindicated

• β-carotene: Grade D recommendation—DO NOT USE. 1
  • Increases lung cancer risk in smokers and those with asbestos exposure. 1
• Vitamin E: Grade D recommendation—DO NOT USE for disease prevention. 1
  • Provides no net benefit for cardiovascular disease or cancer prevention. 1

Vitamin D for Fall Prevention

• DO NOT prescribe vitamin D supplementation specifically for fall prevention in community-dwelling elderly. 4
• The USPSTF recommends AGAINST vitamin D for fall prevention (Grade D). 4
• This does NOT contradict the recommendation for vitamin D 800 IU daily for bone health—the indication differs. 2

High-Dose Single Nutrients

• Avoid high-dose vitamin A: Reduces bone mineral density at moderate doses; hepatotoxic and teratogenic at high doses. 1
• Avoid exceeding upper intake levels for vitamins A and D: Known harms above tolerable limits. 1

---

Special Populations

Dementia Patients

• DO NOT offer micronutrient supplements to persons with dementia unless specific deficiency is documented. 1
• If deficiency exists, supplement with normal doses, not mega-doses. 1

Polymorbid Medical Inpatients

• Provide complete micronutrient supplementation (multivitamins + multi-trace elements) to meet reference nutrient intakes, with potential temporary increases to replete depleted stores. 4
• Incomplete supplements not designed for repletion are ineffective. 4

Frail Elderly

• Oral nutritional supplements (ONS) with high protein content (>20% energy from protein) improve nutritional status, reduce complications, and decrease fall risk. 4
• Multiple micronutrient deficiencies are strongly associated with frailty. 1

Very Old (≥80 Years)

• The same core recommendations apply, with heightened vigilance for deficiencies due to increased prevalence of hypochlorhydria, medication interactions, and reduced dietary intake. 4, 3

---

Protein Considerations (Not a Supplement, But Critical)

• Elderly should consume 1.0-1.3 g/kg body weight/day of protein, distributed across meals. 2
• High-quality protein sources: meat, poultry, fish, dairy, eggs, beans, peas, lentils, nuts. 2
• Protein intake preserves muscle mass and prevents sarcopenia. 2

---

Treatment of Documented Deficiency

Vitamin B12 Deficiency

• Without neurological involvement: Hydroxocobalamin 1 mg IM three times weekly for 2 weeks, then 1 mg IM every 2-3 months. 3
• With neurological involvement: Hydroxocobalamin 1 mg IM on alternate days until no further improvement, then 1 mg IM every 2 months. 3
• Critical pitfall: Never treat folate deficiency before checking and treating B12 deficiency—may precipitate subacute combined degeneration of the spinal cord. 3

Iron Deficiency

• Monitor iron status regularly; supplement only with documented deficiency. 2
• Include iron-rich foods: meat, poultry, fish, eggs, beans. 2
• Consume tea between meals, not with meals, to avoid absorption interference. 2

---

Practical Implementation Algorithm

1. Screen all elderly ≥65 years for:

   • Dietary intake adequacy (energy <1,500 kcal/day?) 1
   • Involuntary weight loss (>10 pounds or >10% in <6 months?) 1
   • Institutionalization or frailty status 4
   • Medication use (antacids, PPIs) 3

2. Prescribe universally:

   • Vitamin D 800 IU daily 2
   • Calcium to reach 1,200 mg total daily (dietary + supplement) 2
   • Vitamin B12 4-6 μg/day 1, 3

3. Add complete multivitamin/multi-trace element supplement if:

   • Reduced dietary intake (<1,500 kcal/day) 1
   • Malnutrition risk or documented deficiency 4, 1
   • Institutionalized or frail 4

4. Avoid:

   • β-carotene and vitamin E 1
   • High-dose single nutrients (vitamin A, D above upper limits) 1
   • Multivitamins in healthy, well-nourished elderly 1

5. Monitor and adjust:

   • Reassess nutritional status every 3-6 months 4
   • Check serum 25(OH)D, B12, and other micronutrients if clinical suspicion of deficiency 3

---

Common Pitfalls to Avoid

• Prescribing multivitamins alone without trace elements in those with general micronutrient depletion. 4
• Using vitamin D for fall prevention rather than bone health—the evidence does not support fall prevention. 4
• Treating folate deficiency before B12 deficiency—may mask B12 deficiency and cause neurological damage. 3
• Assuming adequate intake equals adequate status—absorption issues (hypochlorhydria, antacids) are common in elderly. 3
• Prescribing β-carotene or vitamin E—explicitly contraindicated. 1
• Ignoring protein intake—micronutrient supplementation without adequate protein is insufficient for preventing sarcopenia. 2